Dear Patient, We welcome you to Stony Brook Dermatology

DEPARTMENT OF DERMATOLOGY
Dear Patient,
We welcome you to Stony Brook Dermatology Associates. It is important not to rush through these forms
since important (requested) data such as your medical history must be accurate and thorough. If you are
unsure of any section, leave it blank and we will assist you when you arrive.
Please remember to bring your completed forms, your insurance card so that we can scan it into your
electronic medical record and your referral (if applicable). Insurance referrals authorize payment for
medical services & if you are insured with a carrier that requires one, it is your responsibility to obtain it &
confirm that it has either been submitted electronically by your primary care physician (PCP) and or
received in the office. If you need the ID# for the dermatologist you will be seeing here, we are more than
happy to provide you with the information you need to ease the process. All (paper) referrals should be
sent to fax# 631-638-4220.
We respectfully request a minimum 24hr. advance notice if you need to cancel or reschedule your
appointment to avoid incurring a “No Show” fee. We understand that you may have changes to your own
schedule however, our goal is to maximize appointment availability to ensure that all patients on our wait
list can avail themselves of unexpected appointment openings.
If you have any questions prior to your visit, please feel free to contact us @ 631-444-4200 and we will be
happy to assist you.
Sincerely,
Julie Bouziotis
Practice Manager
DIRECTIONS
Directions to our office can be obtained by calling our main number @ 631-444-4200 and pressing option 4.






From the LIE (Long Island Expressway) take exit 62 and follow signs for Route 97 N Nicolls
Road. Continue on Nicolls Road to Route 347 (Nesconset Highway) and make a right. At the
3rd traffic light make a left onto Belle Mead Rd. You will be entering Technology
Park. Continue on Belle Mead Rd. to #181 & turn right into the parking lot.
From the NS (Northern State Parkway) please follow it to the end & follow signs for Route
347 (Nesconset Highway). Cross over Nicolls Road and make a left at the 3rd traffic light onto
Belle Mead Rd. You will be entering Technology Park. Continue on Belle Mead Rd. to #181 &
turn right into the parking lot.
From Route 347 (Nesconset Highway) traveling West make a Right onto Belle Mead Rd. You
will be entering Technology Park. Continue on Belle Mead Rd. to #181 & turn right into the
parking lot.
From Route 347 (Nesconset Highway) traveling East you will cross over Nicolls Rd. & make
a left onto Belle Mead Rd. which is the 3rd traffic light. You will be entering Technology
Park. Continue on Belle Mead Rd. to #181 & turn right into the parking lot.
From 25A traveling East make a Right onto Nicolls Rd. traveling South and continue to Route
347 (Nesconset Highway) and make a Left. At the 3rd traffic light make a Left onto Belle Mead
Rd. You will be entering Technology Park. Continue on Belle Mead Rd. to #181 & turn right
into the parking lot.
From 25A traveling West make a Left onto Nicolls Rd. traveling South and continue to Route
347 (Nesconset Highway) and make a Left. At the 3rd traffic light make a Left onto Belle Mead
Rd. You will be entering Technology Park. Continue on Belle Mead Rd. to #181 & turn right
into the parking lot.
NEW PATIENT PAPERWORK PACKAGE “CHEAT SHEET”
Page 1: E-Prescribing Consent Form”
 Please only list known DRUG allergies. If none know indicate N/A
 Enough pharmacy information for us to locate & identify correctly on google search
Page 2: “Communication Consent” – Patient approval regarding private health information (HIPAA)
Page 3: “Ambulatory Care Consent Form”
This form is requesting your consent to receive care in our outpatient facility as well as your confirmation
of receipt of our notice of privacy practices
 Please write in your name & D/O/B
 Sign on the 1st signature line IF you are the patient or patient representative
 Indicate your relationship IF you are NOT the patient who has signed
 Please write in the date
Page 4-5. Agreement for Physician Practices (Billing & HIPAA consents)
Page 6: “Ambulatory Care Summary List”
This is to be complete by the patient or patient’s guardian. This provides your doctor with medical history &
clinical information that becomes part of your medical record (4 separate & distinct categories)
Allergies/Medical Conditions/Past Procedures/Medications
In any section where there is no applicable information for you to enter, please write in “N/A” to indicate that this
is not applicable
Remember that it’s important to provide any & all information within each category that is known to you
Page 7: Related Historical Information Sheet/Primary Care Physician & HIPAA information
PLEASE write your name on top
 These are a series of Yes & No questions – please answer ALL
 Please complete current PCP & Referring physician information
 Don’t forget to answer the permission to discuss your medical condition (HIPAA) question @ the bottom
 Do NOT forget to sign @ the bottom!
Page 8: “Adult Patient Needs Assessment”
It is critical that this be completed in its entirety to ensure that we plan proper accommodations if needed. IF the
patient is a child, the following sections apply to his/her guardian:
 Communication
 Culture
 Learning Preference
 Domestic Concerns
Falls Risk & Nutrition Screen applies to the child/patient
COMMUNICATION CONSENT
STONY BROOK DERMATOLOGY
181 BELLE MEAD ROAD
SUITE 5
SETAUKET, NY 11733
It is the policy of Stony Brook Dermatology not to release confidential information other than face to
face without authorization to do so by alternative methods (Voice Mail/Answering
Machine/Telephone). Any information that will be provided will be released only to the authorized
person (s) listed below.
I authorize Stony Brook Dermatology, and/ or their staff to leave medical information pertaining to my
care by the following methods and will assume responsibility to notify them whenever this information
changes (please fill out all contact information).
Home Telephone: _______-_______-_______
Answering Machine:
Work Telephone: _______-_______-_______
YES ____ NO____
YES ____ NO ____
YES ____ NO ____
Cell/ Voice Mail: _______-_______-_______
YES ____ NO ____
E-mail: _____________________@_________.com
Regular Mail:
YES ____ NO ____
YES ____ NO ____
If you would like to have information released to someone other than yourself, please complete the
following list of authorized people:
Spouse: ________________________________
Tel: _______-_______-_______
Adult Child: _________________________________
Tel: _______-_______-_______
Other (please indicate relation): _____________________ Tel: _______-_______-_______
Print Patient Name: ________________________Preferred Tel: _______-_______-_______
Patient Signature: _______________________________
Pt. Name: ______________________________
M.R.#: ________________________________
State University of New York
UNIVERSITY HOSPITAL
AND MEDICAL CENTER
Stony Brook, New York 11794
D.O.B.: _______________________________
AMBULATORY CARE SUMMARY LIST
Phone (h)______________________________
(c)______________________________
Service: ____________________________________
(w)______________________________
Service Phone # ______________________________
Ambulatory Care Guide Given
□
(date)
__________
Advanced Directive Documents Received from Patient
Description
(date) ________
□ No Known Allergies
Allergies / Adverse Reactions (Describe)
Allergy
□
Allergy
Description
Allergy
Description
Diagnoses/ Medical Conditions
DATE
RESOLVED DATE
DATE
Heart valve problems such as MVP?
Artificial joints?
Hepatitis?
Pacemaker/Defibrillator?
Past Operative/Invasive Procedures
Past Operative/Invasive Procedure
Yes
Yes
Yes
Yes
No
No
No
No
Date
DATE
RESOLVED
Do you need antibiotic prophylaxis? Yes No
If yes, please list__________________________________
Past Operative/Invasive Procedure
Date
Medications (prescribed for or used by the patient)
Start Date
Medication Name
Dose
P
Route
Frequency
- 1 -P
Stop Date
PG1PG
PG 1 OF 2 2009
200
Stony Brook Dermatology Associates Registration Form
Name:
_________________________________________________________________________________________
Last
First
MI
Suffix
□Mr. □Mrs. □Ms. □Miss □Dr
Address:
Street #
City
Street Name
Apt#
State
Zip
Home Phone: ________-________-________ Cell phone#________-________-________ Email address: _____________________
Social Security # _________-_________-_________ Employer:
Primary Insurance: ___________________________ID# ___________________________ Referral Required? Y N
FAMILY HISTORY:
Please indicate if there is a family history of any skin conditions or cancers Y N
Relationship to you – Father/Mother/Sister/Brother/Other__________________________
MEDICAL HISTORY: Please circle yes or no if you have or have had any of the following:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
HEART DISEASE
HIGH BLOOD PRESSURE
BREATHING PROBLEMS
DIABETES
THYROID DISEASE
PROSTATE DISORDER
LIVER DISORDER
STOMACH/INTESTINAL DISORDER
EAR OR EYE DISORDER
JOINT PAIN
HIV/AIDS
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
STROKE
CANCER
SKIN CANCER
ANY SKIN DISEASE
PSYCHIATRIC CONDITION
SEIZURES
WEIGHT LOSS
BLEEDING DISORDER
MIGRAINES
Other ______________________
Please indicate:
Height: ____’____” Weight: ______ lbs.
SOCIAL HISTORY:
1. Do you use Tobacco
Y N
If yes, how much
2. Do you use Alcohol
Y N
Social Weekends Daily (please circle)
3. Occupation ____________________
Females only:
5. Are you pregnant? Y N
4. SINGLE MARRIED
6. Are you breast-feeding? Y N
DIVORCED WIDOWED (please circle)
7. Are you planning to become pregnant? Y N
Primary/Family Physician Name & Address
Referring Physician Name & Address
______________________________________
________________________________
______________________________________
________________________________
Phone #_____________________________________
Phone #
DATE ________/________/________
PATIENT (OR GUARDIANS) SIGNATURE
ADULT PATIENT NEEDS ASSESSMENT
Communication:
Do any of the following apply to you?
 Impaired Vision
 Impaired Hearing
 Reading or Speaking Problems
 Pain
 Concerns about your illness
 None of the above
 Other ______________________________
What is your primary language? _________________________
Do you have difficulty understanding English?
 Yes
 No
Can you read English?
 Yes
 No
What language do you prefer when receiving information? ______________________
Culture:
Do you have any Cultural/ Religious/ Spiritual Practices that are important for us to know to provide your
health care?
 Yes  No If Yes, please describe_____________________________________________________
_____________________________________________________________________________________
Learning Preference:
How do you prefer to learn?
 Reading  Person explaining to me  Seeing/pictures
 Demonstration
 Video/Television
Is there anyone you would like to have with you during your teaching? If so, whom? __________________
Domestic Concerns:
Have you been a victim of mental or physical abuse?
Do you feel that you are currently in danger at home?
 Yes
 Yes
 No
 No
Falls Risk:
Do you have a fear of falling?
 Yes  No
Have you fallen in the last 12 months?
 Yes  No
If you answered “YES” to either of these two questions, please notify staff immediately.
Nutrition Screen:
Have you noticed a decrease in appetite within the last month?
 Yes  No
Have you had an unexplained weight loss (over 10 lb.) over the past 3-6 months?
 Yes  No
Please describe your appetite:  Good
 Fair  Poor  Other _________________________
Patient/Designee Signature:
Practitioner Signature:
Date:
ID#:___________
Date: ______Time: _______
AC2C030 (3/12)